DEPARTMENT: System - Administration.
Provides direction, leadership and coordination of all Continuous Survey Readiness preparation and on-sites activities for The Joint Commission, as well as other accreditation or regulatory responsibilities as required. Coordinates and communicates the process of continued readiness for announced and unannounced surveys, standards compliance, with primary responsibility for he National Patient Safety Goals and related patient and co-worker safety initiatives. Creates and main data bases to support and drive accreditation functions. Participates in quality and process improvement initiatives. Actively engaged with changes and updates to accreditation and regulatory standards. Provides education and informational updates to accredited and nonaccredited system entities. Serves as Peer Review Contact for Georgia Hospital Association, Public Health and Accountability and Georgia Medical Care Foundation.
Masters degree in Nursing is required. 5-7 years is required in accreditation, healthcare quality and performance improvement. Professional License with State of Practice is required.